The Tanzanian government’s decision to revise guidelines for HIV services to key and vulnerable populations has forced a Global Fund principal recipient (PR), Save the Children, to suspend two prevention and treatment programs for people from those communities, according to a Fund official. The revision of the guidelines is seen as part of a broader crackdown on the country’s LGBT community that began with a ban on lubricants and has included threats to suspend an organization over allegations that it promoted homosexuality, and arrests of people from the LGBT community.
Health activists are concerned the crackdown will undermine the country’s HIV response. They view the suspended Global Fund programs as an example of how this is already happening.
Tanzania’s Ministry of Health announced it was revising the guidelines in October 2016. In a statement explaining the decision, Health Minister Ummy Mwalimu said her department would continue to collaborate with international partners implementing HIV programming in line with internationally accepted recommendations, but cautioned that “these have to be adapted to the Tanzanian context through consultation with stakeholders to ensure that they are in accordance to the countries’ laws, customs and traditions.” That was read as a specific warning to providers offering services for men who have sex with men (MSM), one of the country’s key populations.
The reasons for the crackdown are unclear, especially since the Ministry has supported efforts to reduce HIV transmission and provide services to key populations in the past, including MSM.
In the wake of Ms Mwalimu’s announcement, though, Tatjana Peterson, the Fund Portfolio Manager for Tanzania, confirmed the suspension of the two programs in an email to Aidspan. The programs were part of a $13 million grant to scale up HIV and TB services in Tanzania, which became active in July 2015 and is scheduled to run through December 2017.
According to the grant agreement, the planned activities included HIV testing and counseling for MSM and transgender people, distributing condoms and lubricants, and diagnosing and treating sexually transmitted infections.
“The Global Fund is deeply concerned about any action that would reduce access to health services for people in need,” Ms Peterson wrote. “We will need to continue to work with the government of Tanzania as we strive to see that access to health services for key populations affected by HIV is maintained.”
Ms Peterson said the Global Fund has been in contact with the government on the issue and remains “hopeful that a solution to ensure continued access to health services for key populations affected by HIV will be found.”
Officials with Save the Children in Tanzania did not respond to a request for comment.
Aside from the grant to Save the Children, the Global Fund lists three additional active HIV grants in Tanzania. The country's Ministry of Finance is the principal recipient for two of them, totaling more than $831 million. A third, run by Population Services International, is focused on condom procurement. Though still listed as active on the Global Fund website, Ms Peterson said grant-supported programs officially ended in December 2016.
The adult HIV prevalence rate in Tanzania is 4.7%, according to UNAIDS, and an estimated 1.4 million people were living with the disease as of 2015. The rate is much higher among key populations, according to the most recent government statistics. Prevalence among MSM is estimated to be 22.2%.
A key government policy document, the Multi-Sectoral Strategic Framework for HIV and AIDS, acknowledged that HIV transmission rates among key populations “are not being adequately controlled” and said, “strong political and government commitment and leadership will also be needed to increase demand among Tanzania’s underserved and key populations.”
Instead, activists for health and LGBT rights said recent government activities are reducing HIV services for key populations and making it less likely members of those communities will access them where they do exist. UNAIDS officials in Tanzania told Aidspan that partners implementing programs for key populations have reported a “significant decrease” over the past several months in the number of people from those communities taking advantage of their outreach efforts or attending facility-based services.
Though Ms Mwalimu’s announcement is the most high-profile development, health activists said the first incident came in July 2016 when the Ministry of Health banned lubricants and threatened to de-register projects that continued to distribute them.
UNAIDS has recommended that to reduce transmission of HIV water- or silica-based lubricants should be made available along with condoms, and has particularly recommended they be used during anal intercourse. In Tanzania, the Multi-Sectoral Framework also calls for targeted and innovative strategies to increase access to water-based lubricants, alongside male and female condoms.
Ms Peterson said lubricants have been procured as part of Global Fund-supported programs in the past, including under the grant to Population Services International. She said procurement of lubricants has now been stopped.
Following the lubricant ban, the campaign against key populations and the organizations providing services to them became more overt. Community Health Education Services and Advocacy, a local health service provider, was threatened with deregistration in August for promoting homosexuality, and then had its offices raided weeks later.
In December, the police shut down a meeting of reproductive health providers. Days later, 11 members of the LGBT community living in Zanzibar were arrested, according to reports from a group of health and LGBT rights activists that have been coordinating an emergency response to the government's actions.
And in February 2017, following a new statement from Ms Mwalimu that was supposed to clarify the October announcement, there were local reports that the government was closing 40 drop-in health centers for MSM. In a recent memo, the group of health and LGBT activists said the text, which has only been presented in Swahili, is unclear and they are still awaiting further guidance from the ministry.
The ministerial statement drew a rebuke from the U.S. government. Along with the Global Fund, the President’s Emergency Plan for AIDS Relief (PEPFAR) is a leading funder of Tanzania’s HIV response. In the 2015 fiscal year, the U.S. bilateral initiative invested $290 million in HIV programs, according to its website. In an embassy statement, U.S. officials said they had not been consulted on any policy changes and warned that “data clearly shows that the delivery of services for the most at risk populations through community outreach, including drop in/resource centers, is an effective way to reach these populations and to reach other vulnerable and underserved populations.”
Ms Peterson said the Global Fund is committed to continuing to work in the country and has already started a dialogue on how best to invest Tanzania’s 2017-2019 allocation. The Fund remains “actively engaged with both the state and non-state actors in funding the most impactful interventions and supporting community and health systems,” she wrote.